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ADHD: Key Themes  Newsworthy  Cause of ADHD is SpongeBob Square Pants  Cause of ADHD is starting kindergarten at age 4  Stimulants lead to heart attacks  New York Times 2012/2013 opinion pieces:  Sroufe, Kureishi, Friedman, Brooks: Back to the past  Too much of the news and opinion is mythical (see subtitle of book)

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Facts  ADHD is a neurodevelopmental disorder with high genetic liability  ADHD incurs huge costs to those with high levels of symptoms  All too few people with ADHD have excellent life outcomes—if it’s a gift, in the words of Ned Hallowell, it’s hard to unwrap

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Myths  Medications are poisons, destroying developing brains  Meds help in 80% of cases  May actually be neuroprotective for youth with ADHD  Medication alone is a sufficient treatment  Need family/school intervention for skill building  SEE PART 2 TOMORROW!  ADHD can be assessed and diagnosed in a 10’ office visit  Yet this, far too often, is the national standard  Results in both overdiagnosis and underdiagnosis

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Which genes?  Seemed a simple question years ago: Genes related to dopamine systems and pathways in brain  But any single gene variant explains only a tiny fraction of “ADHD-ness”  ‘Dark matter’ of genetics: missing heritability!  Recent discoveries: genes conferring risk for ADHD are SAME as those conferring risk for schizophrenia, mood disorders, and autism  MUST BE that early influences are epigenetic

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Important New Findings Harold et al. (2013a, 2013b)  Adoption study in UK  Controls for biological relatedness  Even in adoptive families, kids’ levels of ADHD elicit overcontrolling parenting from parents  AND, levels of harshness predict further ADHD symptoms, over time  It’s not all in the genes!

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Ultimate cause?  The “real” cause of ADHD has to be compulsory education (same as for LD)  Certainly, ‘attention’ or ‘impulse control’ genes have been around for the history of our species, but extremes not salient until we made children sit and learn to read  If it’s true that achievement pressure “reveals” ADHD, is it also true that current high rates of pressure are fueling the recent explosion?

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What does not explain variation  Demographics  Hispanic population clearly higher in California, and traditionally the lowest rates of diagnosis  Eliminated a little of the CA-NC difference but not most  **Hispanic rates growing FAST, esp. in California  Rates of health-care providers  Explains other disorders, but not here  State “culture”  May explain regional differences within state -- but not state-by-state per se

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** Consequential accountability  1970s-80s: public school reforms “input focused”  Reduce class size, pay teachers more, etc.  Results not consistent; shift in 1990s to “output focused”  I.e., incentivize test score improvements per se  Consequential accountability—districts get ‘noted’ or even cut off from funds, unless test scores go up  30 states implement such laws <2000  Then, becomes law of the land for all states with No Child Left Behind (takes effect )

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Findings From “triple difference” model  Between , in the 20 “NCLB states,” poorest children showed huge increases in ADHD Dx:  In these states, 59% increase in ADHD dx for kids within 200% of FPL  vs. only 8% in middle- or upper-class kids  Nothing like that in states with previous consequential accountability (all kids in those states went up 20% or so)  Nothing like that in private schools  This trend reverses by 2012, with Obama’s dismantling of NCLB

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Consequential accountability introduced via NCLB was associated with higher ADHD diagnostic prevalence increases among low- income children aged 8-13 from , but there was no association from (unadjusted results) District of Columbia is included within the 21 No Child Left Behind consequential accountability states. NCLB: No Child Left Behind; FPL: Federal poverty level N=24,982 (2003), 22,467 (2007), 24,426 (2011) Sources: 2003, 2007, and 2011 National Survey of Children’s Health

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“Unintended effect”  Accountability laws encourage ADHD diagnosis for at least two reasons:  #1: Diagnosis may lead to treatment, which may help boost achievement test scores  Scheffler et al. (2009), Zoega et al. (2012)  #2: In some states/districts, diagnosed youth are excluded from the district’s average test score!  Gaming the system, although NCLB eventually outlaws this  Why poorest kids? NCLB targets Title I schools

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Psychotropic medication laws  In 2001, Connecticut passed a law ‘pushing back’ against rising ADHD medication use in students  By now, 14 states have passed such “psychotropic medication laws,” of one or more of 3 types:  Schools are prohibited from recommending meds  Schools cannot require meds as a condition of enrollment  Parental refusal to medicate the child cannot, in and of itself, be considered neglect  IN THESE STATES, NO RISE IN ADHD DIAGNOSES FROM , VS. > 50% RISE IN OTHER STATES

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Findings  In the 14 states with these laws, essentially no change in ADHD diagnostic prevalence between 2003 and 2011, versus a > 50% increase in other states!